Nursing Continue Education

Shingles 带状疱疹 / Reading & Sharing

Herpes Zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes varicella (chickenpox). After the primary infection, chickenpox, is cured, the virus becomes inactive, and retreats to an individual’s nerve tissues located near the brain or spinal cord (Nair & Bhimji, 2017). The virus can be reactivated with aging, immune insufficiency, illness, and/or stress; however, the exact cause of the reactivation of varicella zoster virus causing shingles is not known.

The varicella-zoster virus will destroy the neurons in the ganglion nerve to replicate and spread causing pain (Dunphy, Winland-Brown, Porter, Thomas, 2015). The pain from the destruction of ganglion nerves is often the first symptom of shingles before a rash occurs. Vesicular lesions appear from the virus spreading through nerves to dermatome (Dunphy et al., 2015). Shingles typically occur in one nerve at a time. Thus, shingles presents itself as a rash that appears on only one side of the body with accompanying pain, headaches, fever, and blisters. Prior to these symptoms, one may experience pain in the area where the blisters have yet to appear about 3 to 5 days beforehand (Ferri, 2018). These blisters are contagious because they contain the actual virus and will remain contagious upon contact until they are scabbed and healed over. Patients may experience what is called post-herpetic neuralgia, or pain at the site after the breakout, for months or maybe even years after the disease (Ferri, 2018).

 

Incidence and Prevalence: 

Exactly what triggers this reactivation has not yet been determined precisely. External re-exposure to the virus, acute or chronic disease processes particularly malignancies and infections, medications and stress are some of the risk factors (Kawai & Yawn, 2017).

Anyone who has had the chickenpox is at risk for contracting shingles. The CDC (2017) indicates that at least 1 in 3 individuals in the US will be diagnosed with herpes zoster/shingles in their time.  However, based on statistics, the CDC (2017) points out that the incidence rates for shingles is 4 individuals out of 1000 people. Considering that one of the risk factors for shingles is age, for individuals aged 60 years and above, out of 1000 people, 10 cases of shingles are diagnosed. In an annual basis, the CDC (2017) estimates that there are 1 million diagnoses of shingles. Most of the patients are diagnosed only once with shingles. However, one can contract the disease again or even thrice. This is, especially, common among the elderly and in individuals with suppressed immune system. The cases of repeat shingle diagnosis are not known. For hospitalization, at least 4% of the shingle cases require hospitalization. This is attributed to complications that may arise from the condition (CDC, 2017). The CDC estimates that at least 96 individuals die annually from shingles.

 shingles diagram

Physical assessment and examination: 

Shingles can be diagnosed based on the history, physical examination, and laboratory tests. A practitioner focuses on the symptoms presented by the patient which include red rashes with burning pain, often on one side of the body or face. The rashes can be described as itchy and patients may have other accompanying symptoms such as fatigue, headache, or fever. The physical examination focuses on the skin, and checks for the rashes and their location. In addition, a clinician should check for sensitivity to touch in the affected area. Various laboratory tests can be done to confirm the diagnosis. They include cytology, molecular methods such as PCR, electron microscopy, and serology such as the detection of VZV specific IgM (Nair & Bhimji, 2017).

Patients should be asked when pain begins and if they have any changes in vision or hearing because the virus can be dormant in ganglion in the ears and eyes. If they have changes in vision, they should be immediately referred to an ophthalmologist.

Assessment of the mouth, back, ears, and head for rashes is imperative. Often the initial rash will appear as erythema, then change to a papular lesion forming a vesicle (Dunphy et al., 2015). Lesions and skin changes may not appear until 2-3 days following pain initiation. Patients can have assay tests and titer tests performed for definitive diagnosis; however, diagnosis is based more off assessment and symptoms.

 

Education and Treatment Plan:

Shingles does not have a cure. Treatment or care plan focuses on the management of the symptoms such as pain, reducing the risk for complication and speedy recovery. Two drugs, Valacyclovir and Acyclovir can be prescribed to help the patient with speedy recovery as well as reduce the patient’s risks for complications such as vision loss and postherpetic neuralgia (Nair & Bhimji, 2017). For the pain, numbing agents like lidocaine may be provided. Other remedies for pain include injections such as local anesthesia, anticonvulsants like gabapentin, and medications such as codeine (Nair & Bhimji, 2017). Patients should be educated to take medications as prescribed to ensure adequate treatment and better outcomes. Antivirals can be taken with food to avoid complications associated upset stomach. Patients should be encouraged to notify provider before stopping medications for complications.

Home remedies such as a cool bath can also help with the pain. Patient education will involve letting the patient know that the condition is infectious, and that that they can infect those close to them, especially if they have never had chicken-pox. The patient can get a shingles vaccine to help prevent the re-occurrence of the disease (Zhang et al., 2017).

Education on the spread of the virus is very important. Vesicles that are open without crusts can spread the infection to others. Patients should be educated to avoid contact with children who have not been vaccinated against chickenpox or individuals who have not yet had chickenpox. They should also avoid contact with pregnant women and individuals with weakened immune systems. Patients should try to avoid scratching lesions because of risk for infection. Patients who are not immunocompromised can be given a vaccine known as Zostavax to prevent postherpetic neuralgia.

 

Management and follow-up:

It is imperative for medical staff to manage healed vesicles and continue to assess them. Pain relief must continue to be assessed to ensure that chronic nerve pain is not occurring. Patients can be encouraged to use calamine lotions to soothe lesions and prevent scratching that can cause infection. Medications such as gabapentin can be used to treat chronic neuralgia pain.

Follow up appointments should be made to assess lesions, pain, and need for further referrals. If the patient has eye pain from damaged ganglion in an ophthalmic area a referral for an ophthalmologist should be made. A referral may also be required to pain centers if chronic neuralgic pain continues after treatment of shingles.

 

Referrences: 

Dunphy, M. L., Winland-Brown, J., Porter, B., Thomas, D., (2015). Primary Care the Art and Science of Advanced Practice Nursing. Philadelphia, PA: F.A. Davis Company.

Ferri, F. F. (2018). Ferris clinical advisor 2018: 5 books in 1. Philadelphia, PA: Elsevier.

Hadley, G. R., Gayle, J. A., Ripoll, J., Jones, M. R., Argoff, C. E., Kaye, R. J., & Kaye, A. D. (2016). Post-herpetic Neuralgia: A Review. Current Pain and Headache Reports, 20(3). doi:10.1007/s11916-016-0548-x

Kawai, K., & Yawn, B. P. (2017). Risk Factors for Herpes Zoster: A Systematic Review and Meta-analysis. Mayo Clinic Proceedings, (12), 1806. doi:10.1016/j.mayocp.2017.10.009

Nair, P., & Bhimji, S. (2017). Herpes, Zoster (Shingles). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441824/

Shingles | Clinical Overview – Varicella Vaccine | Herpes Zoster | CDC. (2017, October 17). Retrieved from https://www.cdc.gov/shingles/hcp/clinical-overview.html

Zawada, W. P., & Baptista, V. M. (2013). Shingles. Magill’S Medical Guide (Online Edition).

Zhang, D., Johnson, K., Newransky, C., & Acosta, C. J. (2017). Herpes zoster vaccine coverage in older adults in the US, 2007–2013. American journal of preventive medicine, 52(1), e17-e23.

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